197610076-10-21-2021-31-AS-SSTS-C7ZUE2-20211021153024

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610076
Report Date: 10/21/2021
Date Signed: 10/21/2021 03:31:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ELEVATED HOME HEALTH		FACILITY NUMBER:	197610076
ADMINISTRATOR:	GOODWIN, BYRANISHA		FACILITY TYPE:	740
ADDRESS:	44663 2ND STREET EAST		TELEPHONE:	(702) 823-8166
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	2	CENSUS: 0	DATE:	10/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:56 PM
MET WITH:	Byranisha Goodwin, Administrator		TIME COMPLETED:	03:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Shira Stamps and Angela Panushkina, met with Administrator Byranisha Goodwin for a One (1) year Required visit for this facility. Infection control: LPA Stamps reviewed facility mitigation plan (approved on 03/30/21) to make sure licensee was following current infection control recommendations. LPAs informed the Administrator that all visitors should be screened by the staff and asked all infection control questions, check the temperatures, and have all visitors sign-in and sanitize/wash hands. Screening area will be upon entry. LPA arrived at 1:56pm and was greeted by the Administrator. At this time, the Administrator has no residents in care. LPAs informed the Administrator of the purpose of the visit. A tour of the physical plant was conducted with the Administrator at 2:00pm. The facility has three (3) bedrooms and two (2) bathrooms. One (1) bathroom and one (1) bedroom is designated for staff use only. Common Areas: LPAs observed proper furniture in the living room area. LPAs observed the gate around the fireplace to be broken. Administrator stated she will fix the gate and e-mail the photo or receipt. Kitchen: At 2:00pm LPAs observed the kitchen area. LPAs informed the Administrator that all dishwashing liquid or hazardous materials should be in a locked cabinet. LPAs observed knives and sharp objects locked in the hallway closet. LPAs observed future medications will be locked in the hallway closet as well. Continued...

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELEVATED HOME HEALTH	FACILITY NUMBER: 197610076
	VISIT DATE: 10/21/2021

NARRATIVE

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Resident Rooms: LPAs observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. LPAs tested the exit doors auditory system, and it was observed to be operational for each room.

Bathrooms: At 2:05pm LPAs observed all bathrooms. LPAs observed non-skid matts, grab bars, trash cans with lids, and the appropriate “wash your hands” signs posted. Hot water was tested at 2:05pm and measured within regulation at 107.1 degrees F.

Outside: LPAs observed a latch closing gate. LPAs informed Administrator to have a table, chairs, and a covering for residents.

Fire Alarms/Extinguishers: LPAs observed a fire extinguisher in the kitchen and the living room areas. LPAs were unable to observe the service date. The Administrator called "Fletcher Fire Protection" for the fire extinguishers to be serviced and will provide LPA Stamps with the receipt. At 2:08pm the carbon monoxide and fire alarm were tested and in working order.

Exit interview was conducted and a copy of this report was sent to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

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